North Carolina Health and Wellness Trust Registered...

North Carolina Health and Wellness Trust Registered Dietitian Billing Guide 2010 1

North Carolina Health and Wellness Trust

Registered Dietitian Billing Guide

2010

Any opinion, finding, conclusion or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view and policies of the North Carolina Health and Wellness Commission. This guide has been edited to reflect accurate billing practices and advice for all RDs nationwide. A version of the guide with information specific to North Carolina is also available at www.eatright.org/members/billguide11.

IN4Kids Project

http://www.eatright.org/members/billguide11�


Table of Contents

I. Introduction

II. National Provider Identifier, Credentialing, and Council for Affordable Quality Healthcare

Obtaining a National Provider Identifier Credentialing with Insurance Companies

What is the Council for Affordable Quality Healthcare?

III. Insurers and Coverage, Procedure Codes, and

Diagnosis Codes Insurers and Coverage CPT or Procedure Codes ICD-9-CM or Diagnosis Codes

IV. Verifying Insurance Coverage and Benefits

V. Filing Insurance Claims Understanding CMS 1500 forms Electronic Claims Submission

VI. Appendix


This manual was written by: Jaime Lynn Lewis, RD, LDN Owner Contemporary Nutrition, Inc. Havelock, NC Gwen Murphy, MS, PhD, RD, LDN Assistant Consulting Professor Division of Community Health Department of Community and Family Medicine Duke University Medical Center Durham, NC Kathryn Kolasa, PhD, RD, LDN Professor and Section Head Nutrition Services and Patient Education Brody School of Medicine Department of Family Medicine East Carolina University Greenville, NC Pam Michael, MBA, RD Director, Nutrition Services Coverage American Dietetic Association Chicago, IL Kim Koltzau, RD, LDN Program Manager Take Charge Weight Initiative Guilford Child Health, Inc. Greensboro, NC We would like to thank the following for their helpful comments in preparing this guide: Sheree Vodicka, Betsy LaForge, Shelia Garner, Karyn Evans, Cara Elio, Mia Chabot, Andrea Nikolai, Heather Foster, Rachel Kroll, Melissa Smith, Nidu Menon, Cameron Graham, Anthony Meachem, Josephine Cialone, and Cathie Ostrowski.


I. Introduction This billing guide is intended to assist registered dietitians, medical practitioners, practice

managers, billing personnel, and practice plans in the intricacies of reimbursement for medical nutrition therapy (MNT) particularly with regard to obesity. It was developed with funding from the North Carolina Health and Wellness Trust Fund. North Carolina has been a leader in providing reimbursement for MNT. Starting in 2003, the Health and Wellness Trust Fund Chair (then) Lt. Governor Beverly Perdue established a committee to study childhood obesity. The task of this committee was to understand the causes of childhood obesity and to develop recommendations to combat this epidemic. Starting in 2005, Blue Cross and Blue Shield of North Carolina (BCBSNC) began covering MNT as part of its Member Health Partnership obesity-related health management program. Medicaid of North Carolina started covering MNT for obesity in 2001. In 2010, as this manual was written, NC State Health Plan and Federal Health Plan added MNT benefits for children who are overweight or obese. In 2009, the Alliance for a Healthier Generation initiated a childhood obesity program that provides eligible children with access to at least four visits with their primary care provider and at least four visits with a registered dietitian. The Alliance convened medical associations, including the American Dietetic Association, insurers and employers to encourage them to provide obesity benefits such as MNT for children and families. Prevention and treatment for obesity is an important benefit to dovetail with the policy and environmental changes that are currently being promoted across the country. Additional details on the Alliance Healthcare Initiative are available at http://healthiergeneration.org. Members of the American Dietetic Association can review RD-specific information for participating in the Alliance Healthcare Initiative by accessing information located at www.eatright.org/alliance. MNT coverage provided by RDs also became effective in 2003 in the federal Medicare Part B program. Currently, coverage is limited to qualifying Medicare beneficiaries with diabetes, chronic kidney disease and post-kidney transplants. Unfortunately, there is no uniformity between and even within insurers with regard to benefits, billing and reimbursement for RDs. This manual was developed under a contract with the North Carolina Health and Wellness Trust Fund to support the efforts of registered dietitians, both in private practice and working in ambulatory healthcare facilities and clinics, to create and implement a business model that will allow them to provide covered nutrition services. This manual includes both information that is available by searching documents and web sites of various insurance providers and information from conversations with insurers. It also provides real-life experiences of North Carolina registered dietitians as they completed


local health plan’s credentialing requirements in order to receive direct reimbursement for the delivery of MNT. We have sought to make this information as accurate and current as possible but cannot be held responsible if the information has changed. Insurance plans and procedures change rapidly and it is the responsibility of the provider to keep up to date on these. Section 2 provides instructions for obtaining a national provider identity and becoming credentialed with insurers. Section 3 outlines nutrition services covered by local insurers and it reviews both Current Procedure Terminology codes (CPT) and diagnostic codes (ICD-9). Section 4 details how to verify coverage and what information the RD should collect from patients prior to the provision of MNT services. And finally, Section 5 provides the ins and outs of filing insurance claims.


II. National Provider Identifier, Credentialing, and Council for Affordable Quality Healthcare

After years of college to complete your degree, your licensure exam, and career planning, there are just a few more steps that you must complete to be reimbursed for Medical Nutrition Therapy. You must apply for a National Provider Identifier (your individual identifying number) and then you must credential (apply to become a provider) with each insurance company. The following pages will explain the details that are involved. While you complete these steps, you may receive payment directly from the patient. What is a National Provider Identifier? The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated the adoption of standard unique identifiers for health care providers and health plans. The purpose of these provisions is to improve the efficiency and effectiveness of the electronic transmission of health information. This is an individual identifying number, much like your social security number. The National Provider Identifier or NPI is a 10-digit, intelligence free numeric identifier (10 digit number). Intelligence free means that the numbers do not carry information about health care providers, such as the state in which they practice or their provider type or specialization. Each time you credential with an insurance company, they will attach your NPI to your name and specialty. Your NPI will not change and will remain with the provider regardless of your job, location, or name changes. What is the NPI used for? The purpose of the NPI is to uniquely identify a health care provider in standard transactions, such as in coordination of benefits between health plans, health care claims, and in patient medical record systems.

● Each time you call an insurance company to verify benefits, they will ask you for your NPI number. (If it is an out-of-state plan, there are times when they cannot find you in their system, so don’t be surprised. You will need to give them your NPI number, name, address, and specialty information.)

● Every claim that is filed will have your NPI number on the CMS 1500 form (**See page 49 CMS 1500) whether handwritten or electronic.

● Many of the medical record systems use your NPI number as part of your signature or sign in process.

Is there a fee to obtain an NPI number? No. There is no fee, only a registration process. How long will it take to get an NPI? The electronic process online will usually issue an NPI number within minutes but may take up to 10 days from the time you apply to get a return email with your NPI number. Completing the process through the mail will take longer.

● National Provider Identifier (NPI)


Tips to expedite your NPI online application

• User IDs cannot be changed. (User ID must be 6-12 characters in length, cannot contain any spaces or special characters and cannot contain more than 4 digits. Password must be 8-12 characters long, contain at least one letter, one number, no special characters, and not be the same as the User ID.)

• Once you have successfully chosen a User ID and secret question/answer combinations and submitted the record, the User ID and secret question/answer combinations will remain tied to your record.

• Use the application’s navigation buttons, NEXT or PREVIOUS. Do NOT use the browser’s buttons, BACK and FORWARD.

• If you have a problem with the system and cannot continue, wait 20 minutes before logging on again.

• Print each page as you complete the application to keep a record of your file.

• Assure that you have plenty of time to complete your application. If you leave before your application is complete, you will have to start over.

Selected Glossary

• An Employer Identification Number (EIN) is assigned by the Internal Revenue Service (IRS) (**See page 18 EIN)

• A Social Security Number (SSN) is assigned by the Social Security Administration. The SSN is furnished only on an NPI application from providers who are individuals. An SSN is required on all web NPI applications.

Where would you apply for an NPI? Apply online at https://nppes.cms.hhs.gov/


Obtaining a National Provider Identifier Step 1: Make sure you have all the needed information

Before you begin, make sure you have the information in the table below. This information will be required to complete the NPI Application Form.

Step 2: Read the 5 statements on the website about truthfulness, verification and privacy.

Step 3: Begin on-line application You will not be able to save your work if you quit before you have completed the application form.

Information Required for Individual Providers

Information Required for Organizations

• Provider Name • SSN • Provider Date of Birth • Country of Birth • State of Birth (if Country of Birth is U.S.) • Provider Gender • Mailing Address • Practice Location Address and Phone

Number (you cannot use a PO Box or Residential Address unless it is your Practice address)

• Taxonomy (Provider Type) (Note: RDs should select the provider type “Registered Dietitian - 133V00000X”)

• State License Information (Your license number from the NC Board of Dietetics)

• Contact Person Name • Contact Person Phone Number and E-mail

• Organization/Business Name • Employer Identification Number (EIN) (if

you have one registered with the IRS) (**See page 18 How to obtain an EIN)

• Name of Authorized Official for the Organization

• Phone Number of Authorized Official for the Organization

• Organization Mailing Address • Practice Location Address and Phone

Number (you cannot use a PO Box or Residential Address unless it is your Practice address)

• Taxonomy (Provider Type)(Note: RDs should select the provider type “Registered Dietitian - 133V00000X”)

• Contact Person Name • Contact Person Phone Number and E-mail


How would you deactivate your NPI number?

You should contact the NPI Enumerator if you want to deactivate your NPI. Health care providers, including physicians and non-physician practitioners, can deactivate their NPIs if the NPIs are no longer required or needed. Reasons for deactivation include retirement, business dissolved, or death of the health care provider. Centers for Medicare and Medicaid Services (CMS) has contracted with Fox Systems, Inc. to serve as the NPI Enumerator. The NPI Enumerator is responsible for dealing with providers on issues relating to unique identification. Enumerator staff will be available to assist health care providers with questions regarding the processing of an NPI application. The NPI Enumerator may be contacted as follows:

By phone: 1-800-465-3203 (NPI Toll-Free) 1-800-692-2326 (NPI TTY) By email: [email protected] By mail: NPI Enumerator PO Box 6059 Fargo, ND 58108-6059


● Credentialing with Insurance Companies

Why would you want to become credentialed with an insurance company?

As recent studies have shown the importance of diet in both preventing and managing disease, many insurance companies have moved toward providing a nutrition and/or weight management benefit for its members. For some third party providers, being licensed or registered as a dietitian may be sufficient. For some companies, the dietitian needs only to be working for a physician that is credentialed by a specific third party payer. For other companies, they may want evidence of experience in providing a particular type of medical nutrition therapy and may require credentialing. Insurers are required to verify that RDs selected to participate in their network possess the necessary education, including continued education, license(s), malpractice coverage, a clean criminal record, skills to provide medical nutrition therapy, and letters of recommendation. Some insurers may set additional criteria such as a specific length of time that you have practiced in that state or the need for specific certifications such as Certified Diabetes Educator.

When do you start the insurance credentialing process? You will want to start the credentialing process at least six months prior to seeing your first patient. Insurance carriers can take up to 60 days to review your application and if there is missing information or missing documents, it may be denied therefore taking longer. State law dictates the timeframe insures have to process credentialing applications. How do you know which insurance companies you would like to credential with? The first step is to identify which insurance companies are popular in your area. If you work for a clinic, the business manager or billing office should be able to tell you which insurers are most common for that practice. If you are in private practice, one option is to contact local primary care practices to see which insurances they accept. These will be your referring physicians and you will want to meet their needs. Start with one or two insurance companies at a time. Each insurance company is different in patient criteria, visit criteria, filing processes, and reimbursement. Do not overwhelm yourself by credentialing with too many at one time, because this may lead to mistakes and inevitably loss of revenue.

Example: Blue Cross Blue Shield of North Carolina requires licensed registered dietitians to be credentialed and contracted in order to become in-network providers of MNT. Medicaid/Medicare does not credential the registered dietitian. Under Medicaid in North Carolina only the physician will need to be credentialed.)

Example: Blue Cross Blue Shield of North Carolina requires registered dietitians to have practiced as a licensed dietitian in North Carolina for at least 1 year prior to becoming credentialed.


Another option is to compare notes with colleagues in your area to see which health plans credential registered dietitians, and who provides reimbursement for MNT with a Registered Dietitian, who reimburses in a timely manner, and which carriers might be at capacity with providers in your specialty. For those who work in an established practice, you will want to speak with the office manager or person in charge of coding and billing to identify the groups that cover patients seen in that practice. How do you credential with an insurance company? Each insurance company is different in the credentialing completion process. Some insurance companies, like Blue Cross and Blue Shield may require that you go through the local or home plan* because you will be working with local provider relations and using the local filing processes. Some facilities may have internal credentialing policies. *A patient’s home plan is the health plan in the state where the policy was contracted. For example, the patient’s home plan may be with Blue Cross and Blue Shield of Michigan but the patient is currently in North Carolina.. With Blue Cross and Blue Shield, you will file all of your claims directly with your local North Carolina Blue Cross Blue Shield. If the policy is from a state other than North Carolina, Blue Cross Blue Shield of North Carolina’s Inter-Plan Programs Department (BlueCard) will be responsible for processing the claim in accordance with the subscriber’s benefits through their home plan. However, payment to you is determined by your negotiated rates with BCBS of North Carolina. Recredentialing

Periodically, you will need to recredential with the insurance company. This typically is required every three years. Insurance companies will send you a letter, fax, or email to inform you that you have “x” number of days to recredential. They will send you a copy of your Uniform Application and you will make any corrections to that form (example: License Expiration Date), provide a copy of your current malpractice insurance face sheet noting limits of coverage and effective and expiration dates of the policy (the provider name will need to be listed on this sheet), and a new copy of your attestation statement. (**See page 15 CAQH Credentialing Data Review and Attestation) Since this entire process is so time consuming, the development of the Council for Affordable Quality Healthcare was developed. At this time, not all insurance companies are participators in this program which makes the previous section necessary.

Example: ECU Physicians is a Delegated Credentialing Entity. This means they credential their own providers and allow our commercial carriers to audit their credentialing policies and procedures. Their providers complete the Uniform Application to be processed and approved internally.


What is the Council for Affordable Quality Healthcare? The Council for Affordable Quality Healthcare or CAQH (www.caqh.org)has developed an online service intended to eliminate the need for multiple insurance credentialing submissions. In short, you complete one form for all of their participating insurance carriers and you authorize who will receive your information. The CAQH Universal Credentialing Datasource is located at: https://upd.caqh.org/oas. The CAQH has a Universal Provider Datasource which permits providers (the registered dietitian) to enter all the same data required on the paper application into a secure on-line database. This requires the provider (the registered dietitian) to contact the insurance company, to whom they are applying to become credentialed with, who in turn registers the provider (the registered dietitian) with the Council for Affordable Quality Healthcare. The CAQH then issues a registration number and notifies the insurance company who then forwards the identification number to you (the registered dietitian). The provider (the registered dietitian) creates an account with the CAQH’s Universal Provider Datasource and completes all the required information on-line. The provider (the registered dietitian) then faxes the necessary licenses, signature pages and insurance face-sheets. The CAQH Universal Provider Datasource then distributes this information to participating insurance companies who either approve or deny the application and notify the provider (the registered dietitian) by mail. A list of participating insurance companies with CAQH can be found at: http://www.caqh.org/ucd_health_participating.php What are the Benefits to participating in a Universal Credentialing Program?

• Saves time: Filling out multiple forms can take hours, especially when a practice contracts with multiple health plans. CAQH eliminates the need to fill out multiple, redundant and time-consuming forms.

• Minimizes paperwork: Health plans traditionally require providers to update credentialing information every two or three years. For providers who contract with multiple health plans, this can mean an almost constant stream of paperwork. With CAQH, credentialing and other updates are conveniently fulfilled online in a matter of minutes.

• Keeps information current Keeping practice information up-to-date isn't just important for credentialing purposes, it's important for health plan records and directories too. With CAQH, a healthcare provider only needs to update information that has changed. There's no need to fill out information forms over and over again. (**See page 16 Attestation Form)

• And there is not a fee for this service!

● Council for Affordable Quality Healthcare


Example: CAQH Application Requirements

Healthy Nutrition


If you are already credentialed with an insurance company that participates with CAQH, you will need to contact the insurance company and ask them to add CAQH on to your policy. CAQH will then contact you with a CAQH Provider ID Number so that you can create a user name and password to complete your Universal credentialing paperwork. Once you receive your CAQH Provider ID #, you will go to www.caqh.org and complete the application process. If you are not credentialed with any insurance companies that participate with CAQH, you will choose the first company that you would like to credential with and when applying, request that they send your information to CAQH. Help Desk & Reference Guide for CAQH The CAQH Provider Help Desk is 1-888-599-1771 CAQH Quick Reference Guide is https://upd.caqh.org/oas/UPDQuickReferenceGuide20080807.pdf Each time you would like to credential with a new insurance company, you will refer them to CAQH (if they participate). Each time that you apply with a new insurance company through your CAQH, you will update your CAQH application with the Credentialing Data Review and Attestation (**See below). You will also be requested to periodically update your CAQH with updated information such as current professional liability insurance policy information. CAQH Credentialing Data Review and Attestation This is like recredentialing with the insurance companies Anytime there is a need for review, you will receive an email notifying you that you should review your information in the Universal Provider Data Source within the next 10 days. If you do not re-attest, many participating insurance companies may be required to contact you directly for credentialing materials. To complete the re-attestation process, please follow these steps: 1. Log onto the Online Application System (https://upd.caqh.org/oas) using your Username

and Password. 2. Check the Attachments tab to see if any supporting documents (example: proof of

professional liability insurance) need to be updated. If so, please be sure to update the appropriate expiration date by going to that section(s), updating the field(s), and click the 'Audit' button at the bottom of page.

3. Go to the Audit tab and select Run Audit. 4. Go to the Attest tab, and follow the quick 3-step attestation process to finalize your

updates.

Example: with Blue Cross Blue Shield, you can complete an “Online Request to send to CAQH Application” http://www.bcbsnc.com/content/providers/caqh/index.htm Go to the bottom of the page and click “Please complete an online request form to obtain a CAQH provider number” and they will apply for a CAQH number for you and send you your information.


Example: CAQH Attestation Form (which will also be used for Re-attestation)

Each time you complete this process, you will print off a cover sheet and your Attestation Statement (that allows CAQH to share information with each insurance company that you participate with).


Example: Fax Cover Sheet for CAQH

Common Attachment IDs that you will use 003 Current Professional Liability Insurance Policy Face Sheet 007 North Carolina State License 016 North Carolina State Release Your initial application will require 014 References 004 W-9

ID# Name Address City, State, Zip


You will then receive an email stating “We are pleased to confirm that the reattestation for your application data was successful.” Employer Identification Number (You will need this only if you are in a private setting) What is an Employer Identification Number (EIN)? An Employer Identification Number (EIN) is a nine-digit number that the IRS assigns in the following format: XX-XXXXXXX. It is used to identify the tax accounts of employers and certain others who have no employees. The IRS uses the number to identify taxpayers that are required to file various business tax returns. There is detailed information available at the IRS website. http://www.irs.gov/businesses/ It is also recommended that you speak with your accountant or business advisor regarding what form of business entity to establish. Your form of business determines which income tax return form you have to file. How do you know if you need an EIN? Any person (or entity) that files taxes needs an identification number of some kind. It's how the IRS tracks who's paying what to where and when. When you work for someone else, your social security number is used. If you are going to employ workers, you are generally required to withhold, deposit and report employment taxes. To file the various tax returns, including employment tax returns, you need an Employer Identification Number (EIN). However, a sole proprietor may use his or her social security number in lieu of an EIN if the business has no employees and is not required to file excise, employment, alcohol, tobacco, or firearms returns. A sole proprietorship is the only type of business that may use a social security number rather than an EIN. If you are a sole proprietor you can still have a business name. You can either name your business Jane Doe, Dietitian or Jane Doe, doing business as (dba) “Nutrition Success.”

Reasons to remain a sole proprietor (self-employed) under your Social Security Number

► The first advantage is avoidance of double tax. What is double tax? Corporations pay income tax separately from their owners. Double tax can occur when you (through your personal tax return) and your business (through its corporate tax return) must both pay taxes on the same dollar of income. (Example*: If your Gross Salary is $35,999.98, as an employee, you might pay $7359.00 on personal taxes withheld [as you would with an employer] AND $3342.68 taxes AS the employer. If you are self-employed, you will still have to pay self-employment taxes, which is generally a higher tax rate than your personal taxes withheld, but not as large of a percentage of your cash flow is being paid out. * These tax rates have many variables and this is a just one example. Consult your tax advisor or IRS website for additional tax/accounting information.

► The second tax advantage of sole proprietorships is that you can deduct your business losses to the extent of your total income that you may have from all sources,


including interest, dividends, and gains from the sale of non-business property. Furthermore, if you are married and file a joint tax return, your business losses will also offset your spouse's income.

Reasons to explore other business entities available to you: ►The principal disadvantage of sole proprietorships is that you, the sole proprietor, are

personally liable for all the debts of your sole proprietorship. (Example: Say a patient sues you. Your patient can look to all of your personal and business assets including your bank accounts, vehicles, equipment, and perhaps even your house!)

►A second disadvantage of conducting business as a sole proprietorship is that you may pay higher income taxes. As a sole proprietor, you report your business income on your personal tax return. While you do avoid double tax this way, if as a single person your total adjusted gross income exceeds $115,000, or as a married person filing jointly your adjusted gross income exceeds $140,000, you may pay income tax at the highest rate. By incorporating your business, you may be able to reduce your tax rate. Additional details on business entity types to consider when setting up an RD private practice can be found on the IRS web page, in general business textbooks, from local business association groups, or an accountant.

Where/How do you get an EIN? There are four ways to apply for an EIN: The Internet EIN application is the preferred method for customers to apply for and obtain an EIN. Once the application is completed, the information is validated during the online session, and an EIN is issued immediately. The online application process is available for all entities whose principal business, office, or agency, or legal residence (in the case of an individual) is located in the United States or U.S. Territories. The principal officer, general partner, grantor, owner, trustee, etc. must have a valid Taxpayer Identification Number (Social Security Number, Employer Identification Number, or Individual Taxpayer Identification number) in order to use the online application. Go to https://sa1.www4.irs.gov/modiein/individual/index.jsp You may obtain an EIN immediately by telephone 5 days a week, Monday through Friday from 7:00 a.m. to 10:00 p.m. (local time), by calling IRS at 800–829–4933. You may use this EIN immediately to file a paper return or make a payment of tax. You may obtain an EIN by completing Form SS-4 (PDF), Application for Employer Identification Number, and faxing it to the IRS for processing. The IRS Fax numbers are provided in the Form SS-4 Instructions. An EIN applied for by fax will be issued within 4 business days. http://www.irs.gov/pub/irs-pdf/fss4.pdf You may also obtain an EIN by completing the Form SS-4 and mailing it to the IRS service center address listed on the Form SS-4 Instructions. By mailing the completed Form SS-4 to the appropriate service center, you can obtain an EIN within 4 to 5 weeks. http://www.irs.gov/pub/irs-pdf/fss4.pdf


Professional Liability Insurance No matter how careful you perform your job, the activities you are involved in on a daily basis can put your career and financial stability on the line. Whether you’re employed, self-employed, work full time or part time, or are a student practicing under supervision, having your own professional liability coverage is an important service to purchase for your business. Most, if not all, health plans require professional liability insurance for practitioners whom the plan credentials as network providers. If you work for a large organization or office, contact your office manager or legal department to determine what coverage is provided for you. You may opt to have additional coverage. Professional liability insurance is available through several vendors. ADA membership allows members an opportunity to receive affordable group rates on professional liability insurance. https://www.personal-plans.com/ada/welcome.do (The direct link for Marsh is https://www.proliability.com/). There is an annual cost for this policy which varies based on if you are employed, self employed, or student, the number of hours you work, and your specific coverage. The cost is generally less than $150/year. Additional coverage for property and employees can also be added to the RD’s professional liability plan. W-9 Form (Request for Taxpayer Identification Number and Certification) A Form W-9 is a document issued by the United States Internal Revenue Service (IRS) for certain taxation purposes. While W-9's aren't filed with the IRS, they are collected by the insurance companies that hire independent contractors. This form and instructions can be located at http://www.irs.gov/pub/irs-pdf/fw9.pdf. You will need to complete a copy of this form for CAQH or each of the insurance companies you credential with. Completing the W-9 Form If your NPI that you are using was established as an individual using your Social Security Number, you will list your Individual name as shown on your income tax return on the “Name” line and your address. You may also enter your business, trade, or “doing business as (DBA)” name on the “Business name” line. If your NPI that you are using was established as an organization using an Employer Identification Number, you will list your Business name as shown on your income tax return on the “Name” line.

Part I – Taxpayer Identification Number (TIN) If your NPI that you are using was established as an individual using your Social Security Number (SSN), you will provide your SSN on this line of the W-9 Form. If your NPI that you are using was established as an organization using an Employer Identification Number (EIN), you will provide your EIN on this line of the W-9 Form. Part II – Certification Read and sign


Once Credentialed, the Contract is Next; Contracting and Provider Relations Provider relations usually consist of specialist, coordinators, contracting, and network management. Each insurance company uses different titles to explain the different positions in their company. If you are individually credentialed with an Insurance Company, you will work closely with a member of the Provider Relations Team to complete your contract. For large organizations, contact your office manager or the billing and reimbursement department in your practice to determine how existing contracts affect your work.


III. Insurers and Coverage, Procedure Codes, and Diagnosis Codes

There are not any two insurance companies that have the exact same policy. And within any company, two policies can also be totally different. This section focuses only on the patient’s MNT benefits. We will be discussing procedure codes and diagnosis codes in the sections to follow. If you are a private practice registered dietitian doing your own billing, you need to understand the intricacies of the policies to ensure you receive compensation for your work. If you work for a large medical organization, the individual in charge of billing and reimbursement may understand the intricacies of billing for physician and laboratory services, but may have no experience in billing for medical nutrition therapy. It may be necessary for you to provide information, such as that included in this manual, to those individuals. Since nutrition/medical nutrition therapy coverage varies across the country, we are not able to list detailed coverage policies in this reimbursement guide. RDs may review ADA’s MNT Coverage Chart for additional coverage information in their state from ADA’s web page at: http://www.eatright.org/Members/content.aspx?id=7784, and also contact their affiliate association's Reimbursement Representative for coverage details in your state. ADA reimbursement representatives can be located on ADA’s web page at: http://www.eatright.org/Members/leadership.aspx?&C=80003209. Factors to consider with nutrition coverage policies:

• Credential & Reimburse Registered Dietitians Some policies credential and reimburse registered dietitians individually. Some policies

do not credential registered dietitians but will reimburse for MNT with a Registered Dietitian. Some policies do not credential registered dietitians, but will reimburse if the MNT services are provided “Incident to” a Physician’s Visit.

“Incident to” services are defined as services that are an integral, although incidental, part of the physician's professional service which is commonly rendered without charge or included in the physician's bill and are commonly furnished in physician's offices or clinics and either furnished by the physician or by auxiliary personnel under the physician's supervision.

● Insurers and Coverage

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• Referral needed Some policies require that you have a physician’s referral for a nutritional consult

(written, telephone, etc). Some policies require that you have a written referral to a HMO provider.

• Special Requirements Some policies only reimburse for patients who are enrolled in specific programs (example: Member Health Partnerships with BCBS), are a particular age, or have a particular diagnosis code.

• Benefits for the patient o Deductible

The specified dollar amount for certain covered services that the member must incur before benefits are payable for the remaining covered services. The deductible does not include copayments, member coinsurance, charge in excess of the allowed amount, amounts exceeding any maximum and expenses for non-covered services.

o Copayment (copay) - The fixed-dollar amount which is due and payable by the member at the time a covered service is provided. (Example $25)

o Coinsurance - The sharing of charges by the insurance company and the patient for covered services received, usually stated as a percentage of the allowed amount after the deductible has been satisfied. (Example Insurer pays 80% - Members Coinsurance is 20%). Some policies have a Coinsurance Maximum - The maximum amount of coinsurance that the patient is obligated to pay for covered services per calendar year/benefit period.

o Limit of visits Some policies have a limit to the number of visits covered under the policy, yet some

policies have different coverage criteria for different diagnosis. Some policies may only limit the number of units.

o Limit Units Some policies have a limit to the number of units covered under the policy. (**See

page 45 Units)

o Out-of-Network benefits An In-network Provider has been designated as a provider by becoming credentialed

and contracted with the particular insurance company. An Out-of-Network Provider has not been credentialed or signed a contract with the particular insurance company. In most instances members will incur a higher out-of-pocket expense for utilizing out-of-network providers. However, some benefit plans types will not cover services rendered by an out-of-network provider. This is usually the case for traditional HMO plans.

o Exceptions Some independent or employer-based policies will carve out specific benefits

available to their employees which are the separation of a medical service (or a group of services) from the basic set of benefits in some way whether they do not cover that


particular benefit or they limit coverage in some way. (Example: Some policies do not participate in BCBS’s Member Health Partnership Program)

Locating local coverage policies Since nutrition/medical nutrition therapy coverage varies across the country, we are not able to list detailed coverage policies in this reimbursement guide. RDs may review ADA’s MNT Coverage Chart for additional coverage information in their state from ADA’s web page at: http://www.eatright.org/Members/content.aspx?id=7784, and also contact their affiliate association's Reimbursement Representative for coverage details in your state. ADA reimbursement representatives can be located on ADA’s web page at: http://www.eatright.org/Members/leadership.aspx?&C=80003209. Sample nutrition policies within the government’s federal health program (available nationally) Blue Cross and Blue Shield (BCBS) Federal Health– Standard and Basic Policy Blue Cross Blue Shield coverage policies for federal employee health benefits, in both the Standard and Basic Options, includes “preventive care benefits in full for nutritional counseling visits for adults and children when you use Preferred providers, and we [BCBS] have clarified the types of covered nutritional counseling providers and services. Nutritional counseling when billed by a covered provider such as a physician, nurse, nurse practitioner, licensed certified nurse midwife, dietician or nutritionist, who bills independently for nutritional counseling services Note: Benefits are limited to individual nutritional counseling services. We do not provide benefits for group counseling services. “ Details are included in the 2011 Blue Cross® and Blue Shield® Service Benefit Plan at http://www.fepblue.org.

BCBS Federal Health Jump 4 Health Weight Management Program Blue Cross Blue Shield’s Healthy Families Program offers a Healthy Kids Program called Jump 4 Health – a national health education program to assist parents and their children with healthy habits such as weight management, nutrition, physical activity, and personal wellbeing. The Healthy Kids Program also offers information about Healthy Teens and guidance to help parents respond to teen behavior challenges. For more information, go to www.fepblue.org

• Special Requirements Children age 5 through 17 whose Body Mass Index (BMI) falls in the 85th percentile or

higher, according to standards established by the Centers for Disease Control and Prevention (CDC) may be eligible to participate in our new Jump 4 Health Weight Management Program.

The child must enroll in the Jump 4 Health Program, and then simply calculate and submit his or her BMI through BCBS’s Web site, www.fepblue.org. Go to fepblue.org > MyBlue > MyBlue Personal Health Record > Healthy Families > Register now

http://www.eatright.org/Members/content.aspx?id=7784�

http://www.eatright.org/Members/leadership.aspx?&C=80003209�

http://www.fepblue.org/�




• Benefits for the patient

o Deductible $0

o Copay/Coinsurance See above policy information If the child meets the criteria for

participation, we {BCBS] will provide him or her with a program certificate. The certificate will entitle the child to receive up to 4 nutritional counseling visits per year at no charge and the copay/coinsurance will apply for the remaining.

o Limit of visits 4 visits

o Limit Units None

o Out- of- Network benefits None

o Exceptions None

o RD completes the “My Blue Wellness Certificate” (see page 26) with each child


Example: Nutrition Counseling Certificate


● CPT or Procedure Codes

CPT (Current Procedural Terminology) or procedure codes are numbers assigned to every task and service a medical practitioner may provide to a patient. They are then used by insurers to determine the amount of reimbursement that a practitioner will receive by an insurer. This code set is maintained and copyrighted by the American Medical Association (AMA), and adopted by the Secretary of Health and Human Services as the standard for reporting physician and other services on standard transactions. These are typical billing codes accepted by most insurance companies including federal and state programs such as Medicare and in some cases Medicaid.. A variety of payers require RDs to use the MNT CPT codes for nutrition services covered by the plan. Check payer policies to verify CPT codes to use on claims.

97802

Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minute unit. (**See page 45 Units)

97803

Re-assessment and intervention, individual, face-to-face with the patient, each 15 minute unit. (**See page 45 Units)

97804

Group [2 or more individual(s)], each 30 minute unit. (**See page 45 Units) You will bill for the number of units that you are face-to-face with the patient.

CPT codes, descriptions and material only are copyright ©2009 American Medical Association. All rights reserved. Determining units of MNT codes to report on claims

RDs should report the number of units based on the time that you interact and provide services to the patient. Note, time spent preparing for your visit with the patient, pre or post visit activities, are not billable hours and should not be include in the unit of MNT codes reported on the claim. (**See page 45 Units)

Example: If you met with Patient A for 1 ½ hour for an initial consult, you would use procedure code 97802 x 6 units. If you met with Patient B for a 30 minute group session, you would use procedure code 97804 x 1 unit.


● ICD-9-CM or Diagnosis Codes

● Healthcare Common Procedure Coding System (HCPCS)

The Healthcare Common Procedure Coding System (HCPCS codes) are established by the Center for Medicare & Medicaid Services (Alpha-Numeric Editorial Panel) and primarily represent items and supplies and non-physician services not covered by the American Medical Association's CPT codes. Medicare, Medicaid, and private health insurers may use HCPCS procedure and modifier codes for claims processing. Check payer policies to determine if HCPCS codes should be used on claims in place of CPT codes for nutrition services.

Examples of nutrition related HCPCS codes:

S9465

Diabetic management program, per dietitian visit

S9470

Nutritional counseling, per dietitian visit

The International Classification of Diseases, Clinical Modification (ICD-9-CM) is a classification used in assigning codes to diagnoses associated with inpatient, outpatient, and physician office utilization in the U.S. Under this system, every health condition can be assigned to a unique category and given a code, up to six characters long. When filing claims, you will need to check the insurance policy to determine if coverage is available for the specific disease or condition (ICD code) for nutrition services.

Although RDs have been advised that it is out of their scope of practice to determine a client’s medical diagnosis, reporting a diagnosis code on a claim, based on information provided by a physician or health care team, is a normal business practice. If physician information, such as the medical diagnosis, is not available, RDs should use the best available information to determine the diagnosis code to list on the claims form in accordance with payer claims processing policies. The use of a medical diagnosis code on a claim does not constitute a medical diagnosis by an RD for legal purposes; however, RDs should check with providers to see if a policy exists for reporting the medical diagnosis on a claim when a physician- derived diagnosis is unavailable. (1) (1) Referral Systems in Ambulatory Care—Providing Access to the Nutrition Care Process, Kren K. et. al., Journal of the American Dietetic Association. August 2008 (Vol. 108, Issue 8, Pages 1375-1379).


ICD-10-CM The government and private health plans are converting from the ICD-9-CM diagnosis code data set to ICD-10-CM. The compliance date for implementation of the International Classification of Diseases, 10th Edition, Clinical Modification/Procedure Coding System (ICD-10-CM/PCS) is October 1, 2013 for all covered entities. For further information on ICD-10-CM, go to http://www.cms.hhs.gov/ICD10/01_Overview.asp

Example: Blue Cross and Blue Shield Federal will cover any ICD code that shows medical necessity for Nutrition Therapy at 100% after their deductible and co-pay/co-insurance except the ICD code 278.01 - Morbid Obesity. Blue Cross and Blue Shield State Health Plan will cover the ICD code 250.xx – Diabetes for Nutrition Therapy at 100% for 6 visits each year, but will only cover 4 visits with a $25 copay for any other ICD code if it is medical necessary Nutrition Therapy.


Common ICD-9-CM codes are:

Source: International Classification of Diseases 9th Revision, Clinical Modification, ICD-9-CM 2010 for Physicians, Volumes I & II, copyright 2009, Contexo Media. (Note, diagnosis codes are updated at least

annually, check payer policies and/or with the referring physician to verify correct diagnosis code.) Nutritional counseling for the treatment of anorexia or bulimia may not be eligible for benefits when provided by registered dietitians. Check payer policy. Complex eating disorders are primarily considered part of a member’s mental health benefit.

Abnormal Weight Gain 783.1 Anorexia / Loss of Appetite 783.0 Celiac Disease 579.0 Chronic Kidney Disease 585.9 Congestive Heart Failure 428.0 Diabetes Mellitus (Insulin Dependent) 250.01 Diabetes Mellitus (Non-Insulin Dependent) or unspecified without mention of complication 250.00 Dietary surveillance and counseling V65.3 Diverticulitis of colon (without hemorrhage) 562.11 Dysphagia 787.2 End Stage Renal Disease 585.6 Esophageal reflux 530.81 Failure to Thrive Child (Lack of expected normal physiological development in childhood) 783.4 Fibromyalgia 729.1 Hypercholesterolemia 272.0 Hyperlipidemia 272.4 Hypertension - Unspecified 401.9 Hypoglycemia 251.2 Hypothyroid 244.9 Inappropriate diet and eating habits V69.1 Insulin Resistance 277.7 Irritable Bowel Syndrome 564.1 Loss of Weight 783.21 Malnutrition of moderate degree 263 Metabolic Syndrome 783.9 Nausea and vomiting 787.0 Nutritional marasmus 261 Obesity 278.00 Obesity - Morbid 278.01 Osteoporosis 733.00 Pernicious Anemia 281.0 Polycystic Ovarian Syndrome 256.4 Pre-op Examination V72.84 Protein-calorie malnutrition Severe 262 Sleep apnea-Unspecified 780.57


IV. Verifying Insurance Coverage and Benefits

Information Needed for Verifying Patient Coverage When patients are referred by a physician or call for an appointment, important information that you will need to request from the provider or patient is listed below. A standard referral page or intake of information is often helpful in collecting the needed information. (**See page 34 Sample Referral Page)

• Patient’s Name (as it appears on their insurance card) • Patient’s Date of Birth • Patient’s Insurance Company • Patient’s Insurance Company’s Provider Telephone Number • Patient’s Policy Number

o If this is the only insurance that the patient has, follow to the next question. o If the patient has more than one insurance company, obtain the above information

for each policy. o You will need to file with the patient’s primary insurance policy first. If you are not

credentialed with the primary insurance company, you will have no way to file that policy and therefore will not get a primary denial and will not be able to file the secondary insurance. (**See page 50 Filing Primary and Secondary Insurance Claims)

• Referring Diagnosis or any other diagnosis that the patient may have (It is often helpful to request a Medical History page when patient is being referred from a physician. Some policies may not pay for the referring diagnosis, but may pay for other conditions that the patient may have. Note: Some policies will want a copy of the physician’s referral and if the ‘covered’ diagnosis is not listed on the written referral, the claim will be denied.)

Example: A Blue Cross and Blue Shield Federal patient may have been referred with ICD code 278.01 - Morbid Obesity, but the physician may not have noted that the patient is also Diabetic 250.00 with Gastric Reflux 530.81 and has Hypercholesterolemia 272.0. Blue Cross and Blue Shield Federal will pay for the Gastric Reflux and Hypercholesterolemia. A Blue Cross Blue Shield Out-of-State Policy may only pay for Nutrition Therapy for Diabetes 250.00, but the patient was referred for Morbid Obesity 278.01. The insurance will not pay for the claim if you use Morbid Obesity as your ICD code when billing. If you file the claim with a Diabetes code and they ask for documentation including the Physician’s referral and it is not documented that the physician referred that patient for Diabetes and that you discussed their diabetes with them in your notes, this claim will be denied.

Example: The patient has Medicare as their primary insurance and Blue Cross Blue Shield Federal for their secondary insurance. You are not credentialed with Medicare and are credentialed with Blue Cross Blue Shield. You will not be able to get a primary denial from Medicare because you will not be able to file that claim; therefore you will not be able to file the secondary insurance. If you file the secondary insurance without filing the primary, the patient’s Explanation of Benefits will return with non-payment awaiting explanation from the primary insurance.


Calling the Patient’s Insurance for Verifying Patient Coverage & Benefits In a large clinic or practice, verifying a patient’s insurance coverage for MNT will increase your billings and decrease a large bill for the patient. For a small practice, calling the patient’s insurance company for each and every patient to verify coverage is critical. If a patient is scheduled for an appointment without verifying the coverage, the patient may be liable for a large bill and/or the practice may have to pursue this patient for payment.

Verifying coverage for each patient will not constitute a guarantee of payment (which is noted with a recording or representative each time you call), but will improve your chances of reimbursement. With some policies you may be very familiar with the benefits for the patient, but you will still want to ensure that the policy is still an active policy, that there are not any pre-existing clauses on the policy, or that the patient is enrolled in any appropriate programs (ex. Member Health Partnerships)

• Call the patient’s insurance company with all of the patient’s information available. • Note:

o Date and Time of Call o Representative you speak with o Is this policy active?

• Does the patient have benefits for Procedure Codes 97802 (Initial MNT) and 97803 (Follow-Up MNT)?

• Is the patient’s diagnosis/condition covered under the plan?

- If you are not credentialed with the insurance company, ask… o If they pay for out-of-network services?

If “No”, then ask if there is a reference number for the call. If “Yes”, proceed to the questions below.

- If you are credentialed, ask… o Is there a referral needed? o Is there a deductible? o Is there a co-pay or co-insurance? o Is there a limit to the number of visits? o Is there a limit to the length of visit (units)? o Are there any exceptions?

• Note a reference number for the call. Some representatives will suggest you use their name and date/time of the call. If they are in another state, you may ask what time it is in that state.

Example: Verification of Insurance


Patient’s First Visit On the patient’s first visit, you will need to collect general demographic and health

information from the patient, if you are seeing the patient independently. If you are a part of a practice, all of this information should be available in the patient’s chart.

Demographics

• Full Name • Mailing Address • Contact Numbers (Home, Work, Cellular) • Alternate Contact (Email, Pager) • Gender • Date of Birth and Age • Social Security Number

Health Information

• Weight Loss History • Medical History • List of Medications

If you are in private practice, due to fraud issues, you will need to collect a copy of the

patient’s insurance card (front and back) and a copy of the patient’s driver’s license (must be black and white, no color copies) or other photo ID to verify that the patient is indeed the patient presenting the insurance card.

If you work in a large practice and think you may need to talk to providers outside your clinic or network, check with your clinic manager whether you need to collect a Medical Record Release. You should know the office policies including insufficient fund fees, non-covered charges by the insurance company, collection fees, or no show fees. If you are in private practice, as part of your intake paperwork, you may also collect a Medical Record Release allowing you to talk to any physicians, specialists, or family members. It will also be important to disclose any financial or office policies including insufficient fund fees, non-covered charges by the insurance company, collection fees, or no show fees.


Example: Referral Page


Electronic Claims Submission Services - Verifying Benefits with Blue-e (BCBSNC) With Blue Cross and Blue Shield of North Carolina, you have the option to file your claims using Blue-e versus batch filing or using a filing service. Blue-e is a quick and easy method for filing all of your Blue Cross Blue Shield claims. If you are filing with more than one insurance company, you may choose to use another method of filing. Signing up for this service does not require you to use this service for filing your claim. This service can be very beneficial for verifying benefits.

With Blue-e, you will sign up to use this benefit: http://www.bcbsnc.com/content/providers/edi/bluee/signingup.htm You can go for a tutorial using: https://providers.bcbsnc.com/providers/_help/demo/cms1500_add_claim/cms1500_add_ claim.htm • Once signed in, go to “Eligibility”:

Enter the member number and/or the member last name, first name, and date of birth. A member number, name, and date of birth are required to search for FEP or out-of-state members. You may enter a single date for the date of service, or if left blank, it will search on today's date.

• On the Eligibility page, you will see two tabs “Member Information” and “Benefits” Member Information TAB to see important information including: o Under Member Information, you find the patient’s information including name,

address, DOB, and relationship to subscriber.

Under policy information, you find the patient’s benefit period which is listed under Effective Date. This will be when the patient’s policy renews each year. (This will affect the patient’s annual deductible or annual number of visits.)

Example of Information:

Eligibility for 07/01/2009 - 12/31/9999 Member Information

Remember, the benefits you see on this screen are a summary of member benefits and do not indicate payment when a claim is filed.

Member Information Member Number: YPPW1234567890 Name: JANE DOE Date of Birth: 12/8/1967 Address: 300 HAPPY STREET Sex: Female HEALTHY, NC 12345 Rel. to Subscriber: SPOUSE Policy Information Product: BLUE OPTIONS Effective Date: 07/01/2009

Group Number: 012345 Paid Through/Term Date: 12/31/9999

Group Name: TOWN OF HEALTHY

Insurance Type: BLUE OPTIONS-Underwritten Group


Under member liability summary, you can see what the patient’s deductible is and how much the patient has met of their deductible. (This will be helpful for patients who must meet their deductible before services are covered.) • Under COB (Coordination of Benefits) summary, this will either be blank or read “See

Other Insurance Tab” • Under Additional Information, Pre-existing Condition Waiting Period would be listed or

No Pre-existing Condition Waiting Period

Example of Information:

Member Liability Summary

In-Network Single Family

Coverage Max per Benefit Period

Year-to-Date Remaining

Max per Benefit Period


CoInsurance 40%

$3000.00 $3000.00 $9000.00 $9000.00 Deductible

$1750.00 $1528.83 $5250.00 $5028.83 Out-Of-Pocket

$4750.00 $4528.83 $14250.00 $14028.83

Out-of-Network Single Family

Coverage Max per Benefit Period


Max per Benefit Period


CoInsurance 60%

$6000.00 $6000.00 $18000.00 $18000.00 Deductible

$3500.00 $3278.83 $10500.00 $10278.83 Out-Of-Pocket

$9500.00 $9278.83 $28500.00 $28278.83

COB Information: No other insurance information on file. Additional Information: Pre-existing Condition Waiting Period 06/07/2006 to 06/07/2006


Benefits TAB Under the Benefits tab, click “General Benefit Information”, and then “Other Medical” to see Nutrition Benefits. If there is a copay, coinsurance, or deductible, you will see it listed.

This is an example of a Blue Options policy: Nutritional Counseling Diab In Dmp INDIVIDUAL COVERAGE LIMIT - UNIT Benefits Usage: VISITS: 6; 6 remaining for SERVICE YEAR

Nutritional Counseling Diab Not In Dmp In Network COINSURANCE: 40% per SERVICE YEAR

Nutritional Counseling INDIVIDUAL COVERAGE LIMIT - UNIT Benefits Usage: VISITS: 6; 6 remaining for SERVICE YEAR

Nutritional Counseling Out of Network Diab No Dmp COINSURANCE: 60% per SERVICE YEAR Dmp = Diabetes Management Program Verifying Benefits with Webclaims (Medicaid) With Medicaid, you also have the option to file your claims electronically versus batch filing or using a filing service. Again, you may only use this service to verify benefits. To sign up, visit NC Tracks web site at http://www.nctracks.nc.gov/provider/forms/. You will complete and Electronic Claims Submission (ECS) Agreement for Individuals or Groups. Once you have signed up for this service, you will go to https://webclaims.ncmedicaid.com/ncecs/ to sign in and review patient benefits and claims.


V. Filing Insurance Claims

Claims submission will vary based on the type of facility you will be billing from. Example: The Health Insurance Claim Form (CMS-1500) is used by Allied Health professionals, physicians, laboratories and pharmacies to bill supplies and services. However, if you are in an institution, you will bill on a UB-04 form. Example: Hospitals, rehabilitation centers, ambulatory surgery centers, & clinics. If you do not own your own practice, you should check with your billing department.

Billing the insurance company You may bill the insurance company for your face-to-face time with the patient. This will be billed in 15 minute increments referred to as units. (**See page 45 Units).

You cannot bill for any equipment, goods, or supplies used in carrying out your services. Some offices may use special equipment that may determine body fat, VO2-Maxx, or metabolic rate, which may not be included in standard office services. You may not add these fees, above and beyond the time spent using this equipment, to your charges. If this service is available to the patient above and beyond standard practice, at an additional fee, the provider must provide the patient with notification that these services are not covered and have them sign a release acknowledging that in order to receive these services, they will be the patient’s own expense.

Telephone consultations provided by are generally not -covered services or generally by most insurance companies. Policies are changing however, so check payer policy to see if phone and/or email services are covered and billable by the plan. You may bill patients directly for these services only if this is your standard practice procedure, and the patient has previously received a written statement of this procedure, or your standard procedure for telephone consultations is posted in your office in a prominent location.

Collection of Fees from Patient Except for copayments, a contracted provider shall not collect any amount whatsoever from patients prior to receiving a notification of payment from the insurance company, including, but not limited to Deductible, Coinsurance, or deposit amounts. (**See page 50 Notification of Payment).

Waiving of Fees Provider shall not waive any portion of a Patient’s Deductible, Coinsurance, Copayment or penalty amount that may be required under a Patient’s Health Benefit Plan. Time Limitations for Filing Claims Check payer policies to determine when claims must be submitted in order to receive payment. For example, claims must be received by BCBS North Carolina within 180 days of the date of service. Check local Medicaid policy to determine when Medicaid claims must be received by Electronic Data Systems (claim filing) in order to be accepted for processing and payment.


Billing Rates When you bill an insurance company, you will bill for your usual and customary charges. All agencies will be billed the same fee for ALL recipients who receive the same service from you. Missed Appointments Each insurance company has different policies in regards to these charges. Many medical providers or specialists have started charging a fee to patients that miss their appointments or cancel with less than 24 hours notice. Some insurance plans do not cover charges for missed appointments; check payer policies to verify this. You may be able to bill clients directly for missed appointments only if this is a standard procedure, e.g. no show or missed appointment policy, for your practice, and the member/client has previously received a written statement of this procedure, or your standard procedure for missed appointments is posted in your office in a prominent location. Medicare Part B allows this practice as long as the patient is informed of the no-show policy. In this case, the patient would be billed for the no-show charge, not Medicare or the insurance plan. Check Medicaid policies in your state to determine if missed appointment (no-show) charges can be billed to Medicaid patients.

Example: You may bill all patients $25.00/unit for services, which would be $100/hour. This would be your usual and customary charge. This would be the rate that you bill the patient or if the patient has insurance, the insurance company. You may be reimbursed by Insurance Company A at a rate of $17.40/unit, which would be $69.60/hour. You may be reimbursed by Insurance Company B at a rate of $16.13/unit, which would be $64.52/hour. You may be reimbursed by Insurance Company C at a rate of $21.23/unit, which would be $84.92/hour. These rates would be your reimbursement based on your set fee schedule agreed upon when you contracted with that insurance company. Sometimes fee schedules are merely the reimbursement rate set forth by the insurance company, some fee schedules are negotiable. If you are in a facility, you will want to speak with your contracting department to review your reimbursement rates


● Understanding CMS 1500 Forms

What is a CMS 1500 form? The Form CMS-1500 is the standard claim form used by a non-institutional provider to bill for services. The Form CMS-1500 answers the needs of many health insurers. It is the basic form prescribed by CMS for the Medicare and Medicaid programs for claims from physicians and suppliers. The Form CMS-1500 has space for physicians and suppliers to provide information on other health insurance. It has received the approval of the American Medical Association (AMA) Council on Medical Services.

Based on HIPAA (Health Insurance Portability and Accountability Act) law, some plans may require providers to file claims electronically unless the provider meets certain examptions. Check payer policies. Paper claims are rarely used by practices or private practice RDs due to the overwhelming task of processing paper claims. You should be familiar with paper claims because some insurers may only accept paper claims if you are not credentialed with them or the claim has to be specially reviewed.

Since most paper claims submitted to Medicare and other insurance companies are electronically read using Optical Character Recognition (OCR) equipment, it is very important that the information is clear and easily read.

Troubleshooting Basics: • Use only an original red-ink-on-white-paper Form CMS-1500 claim form which are often

available through Office or Medical Supply companies. • Use dark ink to write or print on the CMS-1500 form. • Do not print, hand-write, or stamp any extraneous data on the form. • Do not staple, clip, or tape anything to the Form CMS-1500 claim form. • Remove pin-fed edges at side perforations. • Use only lift-off correction tape to make corrections. • Place all necessary documentation in the envelope with the Form CMS-1500 claim form. Format Hints: • Do not use italics or script. • Do not use dollar signs, decimals, or punctuation. • Use only upper-case (CAPITAL) letters. • Use 10- or 12-pitch (pica) characters and standard dot matrix fonts. • Do not include titles (e.g., Dr., Mr., Mrs., Rev., M.D.) as part of the beneficiary’s name. • Enter all information on the same horizontal plane within the designated field. • Follow the correct Health Insurance Claim Number (HICN) format. No hyphens or dashes

should be used. The alpha prefix or suffix is part of the HICN and should not be omitted. Be especially careful with spouses who have a similar HICN with a different alpha prefix or suffix.

• Ensure data is in the appropriate field and does not overlap into other fields. • Use an individual’s name in the provider signature field, not a facility or practice name.


The format of CMS 1500 is simply a guide of information that you will need for filing a claim. Many of the online claims processing uses the CMS 1500 as a template for all claims. The information below simply identifies the most requested information required to complete the CMS 1500 form or most online claims programs.

What information is required for a CMS 1500 form? 1) Show the type of health insurance coverage applicable to this claim by marking the

appropriate box. (ex. if a Medicare claim is being filed, check the Medicare box)

1a) Enter the patient's insurance ID Number. (This may be listed as Medicare Claim Number, Medicaid Identification Number, Sponsor’s SSN, Subscriber ID, ID, Identification Number, ID #)

2) Enter the patient's last name, first name, and middle initial.

3) List patient’s birth date. MM = Month (e.g., January= 01) DD = Day (e.g., Jan05 = 05) YY = 2 position Year (e.g., 1998 = 98) Place an “X” on the correct sex/gender.

4) List the insured’s Last Name, First Name, and Middle Initial This will be the primary insured’s information. If the patient is the primary then the

relationship to insured is self (see step 6), then this will be the same information as #2. Many programs will just let you copy the information with shortcut button.

Blue-e (**See page 49 Blue- e) will allow you to leave this section blank for all in-state Blue Cross Blue Shield policies (Blue Options, Blue Advantage, Blue Care, Employer Based Blue Policies, HSA or HRA plans, State Health Plan), but will not allow you to leave this blank for Federal or Out of State Plans.

x

X

123456789

Smith, John J

01 05 78

Smith, Sally L


5) List the patient’s address. 6) Place an “X” over the appropriate relationship to insured. If patient is the primary insured, mark “self” If patient is married to the primary insured, mark “spouse” If patient is the child of the primary insured, mark “child” If patient is a dependent of the primary insured in another format (ex. Dependent

parent), mark “other”

7) Enter the insured's address and telephone number. This should be the address that matches the patient’s insurance card mailings.

When the address is the same as the patient's, enter the word SAME. Blue-e (**See page 49 Blue- e) will allow you to leave this section blank for all in-state

Blue Cross Blue Shield policies (Blue Options, Blue Advantage, Blue Care, Employer Based Blue Policies, HSA or HRA plans, State Health Plan), but will not allow you to leave this blank for Federal or Out of State Plans.

10) There are some cases that you will have to note whether the patient’s condition is due to employment, accident, etc.

12) The patient or authorized representative must sign and enter either a 6-digit date (MM | DD | YY), 8-digit date (MM | DD | CCYY), or an alpha-numeric date (e.g., January 1, 1998) unless the signature is on file.

The patient's signature or the statement “signature on file” in this item authorizes release of medical information necessary to process the claim.

Signature by Mark (X) - When an illiterate or physically handicapped enrollee signs by mark, a witness must enter his/her name and address next to the mark.

18 Healthy Place Apt C

Austin NC

78701 252 111-9876

X

18 Healthy Place Apt C

Austin NC

78701 252 111-9876 S

01/05/2010


13)The patient’s signature or the statement “signature on file” in this item authorizes payment of medical benefits to the physician or supplier.

17)Enter the name of the referring or ordering physician if the service was ordered or referred by a physician (if it is required by the insurance company). Enter the referring, ordering or supervising provider’s first name, middle initial, last name and credentials.

Some Blue Cross and Blue Shield policies do not require a physician’s referral, but some policies do. Check payer policies, and if it is not required, you may leave this blank.

17a) Enter 1G in the small box and the Provider’s UPIN in the larger box to the right.

UPINs or unique physician identification number, are six-place alpha numeric identifiers assigned to all physicians.

17b) Enter the 10-digit NPI number of referring, ordering or supervising provider.

21) Enter the patient's diagnosis/condition. (**See page 28 or Appendix I Diagnosis Codes)

Only one code is required. Enter up to four diagnoses in priority order.

23) Prior authorization number may need to be listed if required by insurance company.

24) There are 6 horizontal service lines in section 24. This will allow you to bill for up to 6 different services or dates of service. Most insurances will not allow dietitians to bill for more than one service in a 24 hour period. Some insurances have limits on how often you can bill for your services.

24a) Enter an 8-digit (MMDDCCYY) date for each service. This will be the same date.

11 06 10 11 06 10

1234567890

Your NPI #

Referring NPI # 0987654321 Joseph H Smith, MD

250 00

401 9


24b) Enter the appropriate place of service code. Code 11 – Office Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.

24d) Enter the procedure code. (**See page 27 CPT or Procedure Codes) Modifiers are not required. Leave blank.

24e) Enter the diagnosis code reference number as shown in item 21 to relate the date

of service and the procedures performed to the primary diagnosis. If more than one diagnosis code is indicated, the provider shall reference only one of the diagnoses code.

24f) Enter the charge for each listed service. (**See page 39 Billing Rates) List dollars

to the left of the dotted line and cents to the right. (Note: Fee amount listed below are for illustrative purposes only.)

11

97802

1

75 00


24g) Enter the number of units representing the length of your visit.

What is a unit? A unit is the direct (one on one; face to face) time spent in patient contact in 15 minutes increments. This does not include time spent with office staff completing paperwork, doing body assessments, or collecting payments unless that time is spent directly with the provider.

For any single CPT code, providers bill for a single 15 minute unit for visits greater than (or equal to) 8 minutes and less than 23 minutes. Time intervals for larger numbers of units are as follows:

Example

1 unit > 8 minutes < 23 minutes = 15 minutes



4 unit > 53 minutes < 68 minutes = 1 hour

5 unit > 68 minutes < 83 minutes = 1 hour 15 minutes



8 unit > 113 minutes < 128 minutes = 2 hours

The pattern remains the same for treatment times in excess of 2 hours.

24j) Enter the rendering provider’s NPI number in the lower unshaded portion.

Medicaid patients: In the case of a service provided incident to the service of a physician or non-physician practitioner, when the person who ordered the service is not supervising, enter the NPI of the supervisor in the shaded portion. Enter NPI in the small box to the left of this.

Example: If a patient had an appointment at 1:00 pm. She arrived at 1:05 pm and started filling out paperwork and was weighed in by the office assistant. You started your consult with her at 1:15 pm and completed it at 1:58 pm. Your visit would be 43 minutes long and you would bill for 3 units.

3

1234567890

0987654321 Your NPI #

Supervising Physician NPI #


25) Enter the provider’s Federal Tax ID (Employer Identification Number or Social Security Number) and check the appropriate check box. Tax identification information is used in the determination of accurate National Provider Identifier reimbursement. Reimbursement of claims submitted without tax identification information will/may be delayed. This section does not need to be completed for Blue-e. (**See page 49 Blue- e)

27) Check the appropriate block to indicate whether the provider accepts assignment. If you are credentialed with a particular insurance agency, you have contracted a rate with them and you will accept their assigned payment.

28) Enter total charges for the services (i.e., total of all charges in item 24f). Generally this number will be the same as the charge for one date of service. If you are completing the CMS 1500 form for more than one date of service for the same patient, this will be the total of all dates of service charges. (Note, the billing charge example below is only for illustrative purposes.)

31) Enter the signature of provider of service or supplier, or his/her representative, and the 8-digit date (MM | DD | CCYY) the form was signed.

Medicaid patients: In the case of a service that is provided incident to the service of a physician or non-physician practitioner, when the ordering physician or non-physician practitioner is directly supervising the service, the signature of the ordering physician or non-physician practitioner shall be entered in item 31. If a physician, supplier, or authorized person's signature is missing, but the signature is on file; or if any authorization is attached to the claim or if the signature field has "Signature on File" and/or a computer generated signature.

This section does not need to be completed for Blue-e. (**See page 49 Blue- e)

33) Enter the provider of service/supplier's billing name, address, ZIP Code, and telephone number.

75 00

12-3456789

X

123-45-6789

or

X

X


Example: CMS 1500 Form


● Electronic Claims Submission Services

Submitting Claims with Blue-e

• If the Blue Cross Blue Shield plan in your state covers nutrition services where RDs can submit claims, you should be eligible to submit claims electronically. Check the plan’s web page for how to submit electronic claims.

• Once RD sign in to the plan’s web page for electronic claims submissions, you may be prompted to go to “Billing”, “CMS1500”, so you can enter the patient’s ID, and “Add a claim”

Submitting Claims with Webclaims (Medicaid), if available in your state The process of submitting claims to Medicaid through electronic media is referred to as electronic commerce services. EDS will process claims submitted through file transfer protocol and asynchronous dial-up.

By submitting claims electronically, providers have the advantage of expedited claims processing and improved cash flow. Electronic claims software includes time-saving features such as automatic insertion of required claims information, retrieval of previously submitted claims from backup files, and generation of lists of commonly used billing codes. Claims submitted electronically by 5:00 p.m. on the cut-off date are processed in the next check write.

Prior to submitting electronic claims, providers must agree to abide by the conditions for electronic submission outlined in the Electronic Claims Submission (ECS) Agreement. The ECS Agreement must be submitted and approved prior to submitting claims electronically, regardless of how claims are submitted – through a clearinghouse, with software obtained from an approved vendor, or through the NCECS Web Tool.

Submitting Claims on Paper with Medicaid There are some situations in which a claim must be submitted on paper. Only claims that comply with the exceptions listed on the Division of Medical Assistance’s (DMA) web site may be submitted on paper. Check payer policy to determine if paper or electronic claims should be used for RD covered services. When completing the paper claim form, use black ink only. Do not submit carbon copies or photocopies, and do not highlight the claim or any portion of the claim. For auditing purposes, all claim information must be visible in an archive copy. EDS uses optical scanning technology to store an electronic image of the claim, and the scanners cannot detect carbon copies, photocopies, or any color of ink other than black. Carbon copies, photocopies, and claims containing a color of ink other than black, including highlighting, will not be processed and will be returned to the provider.


Example: Blue e CMS 1500 - Claim Submission

1.Insured’s ID Number 2.Last Name of Patient First Name of Patient 3.Patient’s Birth Date (enter date without any dashes (01012001) for Jan 1, 2001) Sex (F or M) 6.Patient’s Relationship to Insured (Self or Spouse or Child) 7.Insured’s Address (Only needed if Federal or Out of State) **NOTE: Blue-e has an autofill program for all BCBSNC policies which completes the information for 2, 3, 4, 5, 6, and 7. 21. (1) Diagnosis Code – You must list at least 1 code and reference it in 24 E. (enter code without any decimals – 25000 for 250.00) 24 A. Date of Service (enter date without any dashes (01012001) for Jan 1, 2001) start and finish (usually the same day) B. Place of Service (11 for Office) D.CPT see CPT codes E. The number to the left of the Diagnosis Code (example 1) F. Enter Charges (enter without any decimals – 10000 for $100.00) G. Enter number of units charged (example 4) J. Enter your NPI number (You may enter claims for more than one date of service on the same patient.) 28.Enter your total charges (enter without any decimals – 10000 for $100.00) Click SUBMIT


Example: If the claim is filed for 4 units at $100.00 and the EOB is returned that the patient’s responsibility is $71.40, you will then file the claim with the secondary insurance for $71.40, not $100.00 because that is the agreed upon rate that the primary insurance company contracted with you. You may receive all that you bill for if the secondary insurance company reimburses at a higher rate, or you may receive less.

Filing Primary and Secondary Insurance Claims

When a patient has a primary and secondary (or more) insurance companies, you will file in the order that the patient reports. You will need to wait until the primary insurance benefits are paid or denied before submitting to the secondary insurance. Once you receive the Explanation of Payment (EOP) (**See below – Notification of Payment), you will then document on the claim any write-off or discounts for which the patient is not held responsible, as this will help coordinate the claim correctly on the first submission.

If you file the claim electronically with primary insurance, you will most likely need to send in a copy of the explanation of payment of the primary insurance to the secondary insurance. Do not paste, tape, or staple the explanation of payment to a claim. You may also choose to file the secondary claim electronically, wait for EOP which states that it is awaiting coordination of benefits with the primary. You would then call the secondary insurance company and make a contact and document a reference number of the call along with a fax number you can fax the primary explanation of payment to. Both methods will take time, but electronic claims are much easier to track. Notification of Payment or Explanation of Payment (EOP) or Explanation of Benefits (EOB) Statues in the state where you reside will describe health plan’s legal requirements for prompt payment of medical claims. Check the health plan’s provider manual to determine payment requirements. For example, the insurer may need to provide the following within 30 calendar days after receipt of a claim, send by electronic or paper mail (notification) to the claimant (provider) (Note: check payer policy for particulars in your state for the specific health plan): (1) Payment of the claim. (2) Notice of denial of the claim. (3) Notice that the proof of loss is inadequate or incomplete. (Asking for more information

from you, the provider, Example Medical Records, Physician’s Written Referral, etc.) (4) Notice that the claim is not submitted on the form required by the health benefit plan,

by the contract between the insurer and health care provider or health care facility, or by applicable law.

(5) Notice that coordination of benefits information is needed in order to pay the claim. (Informing you, the provider, that the patient has another insurance company and that you should either file the claim with the primary insurance or that they are awaiting payment from the primary)

(6) Notice that the claim is pending based on nonpayment of fees or premiums.


Health benefit plan claim payments that are not made in accordance with this section shall bear interest at the annual percentage rate of eighteen percent (18%) beginning on the date following the day on which the claim should have been paid. For example, to check Claim Status with Blue-e, the online claims processing system in North Carolina:

• Sign in to Blue-e • Go to “Billing” and then “Claim Status” • Enter the “Member ID” and “Date of Service”

If viewing Federal or Out of State Members, it may take some time for a result and you will have to come back and view these items later.

The screen explanation will look like this, but if you click on the check number you will see details.

HAPPY DIETITIAN

1234567989

123456789

xxxxxx


The table below explains key information on the explanation of payment.


Electronic Funds Transfer (EFT) Electronic Funds Transfer (EFT) is a secure method of claims payment. Many insurances electronically transfer funds directly into the bank account of your choice. Check the health plan’s provider manual or web page for information about EFT. The following outlines the process for setup of an EFT payment to the provider. • Health care provider must submit:

(1) a copy of a voided check or an account verification letter on blank letterhead; and (2) an Electronic Funds Transfer Authorization form is generally sent to the health plan’s Financial Services via fax or through the mail.

• Health care providers must submit a separate Authorization for each provider number to be set up for EFT.

• A provider number may be associated to only one bank account number. • The plan’s Financial Services verifies the bank name and the bank transit or routing

number. • After verification, EFT status is loaded to the BCBSNC claims system. • All EFT payments are made to the group provider number level.

The main challenge of EFTs is identifying the payments that go to your banking account. They do not come in with a detailed explanation of where the deposit came from or whose account this payment should be applied. You must use your EOPs to compare the amount of the deposit.

This is an example of the deposits in a Banking Account

Handling Patient Denials and Errors Patient denials decrease with practice. You learn over time, which policies require which information. There are common entry error mistakes such as patient gender or using today’s date as the date of birth. There are also errors on the end of the insurance company.

Example: A claim with Blue Cross Blue Shield Federal for a patient’s office visit was not paid correctly. The visit was 8 units (2 hours) and was denied because it exceeded the benefit coverage. When called, the representative shared the patient only had 4 visits / year and this visit exceeded the benefit. The misunderstanding was the difference between units and visits. There is not a limit on the number of units, only the number of visits. This patient’s claim was sent for review, paid the claim, and had 3 remaining visits.


Once you receive a claim denial, your first step is to call the insurance company and speak with the claims department. You will then review the claim with the representative to assure that you entered the correct information. Verify that you entered the correct ID #, Name, Date of Birth, Gender, Procedure Code, and Diagnosis Code. Often, this can be resolved easily by resubmitting the claim. Some insurance companies will require you to refile the claim with the words “CORRECTED” across the top. You may be able to resubmit the claim electronically, e.g. through Blue-e, simply by resubmitting all the information from the original claim with corrections and choosing “Corrected Claim”.

If there are no errors and the patient’s policy does cover nutrition therapy, have the representative send the claim for review. In some cases the insurance company will ask for additional notes or a copy of a physician referral. With Medicaid Eligibility Denials Check you state’s specific Medicaid policies for reprocessing denied claims. If claims are denied for eligibility reasons, the following steps generally apply and should help resolve the denial and obtain reimbursement for covered dates of service for eligible recipients. Step 1—Check for Errors on the Claim

Compare the recipient’s eligibility information to the information entered on the claim. If the information on the claim and the recipient’s eligibility information do not match, correct the claim and resubmit on paper or electronically as a “new day claim”. If the claim is over the designated claim filing time limit, request a time limit override by submitting the claim and a completed Medicaid Resolution Inquiry form. Include a copy of the Remittance and Status Report (RA) or other documentation of timely filing.

Step 2—Check for Data Entry Errors Compare the RA to the information entered on the claim. If the RA indicates that the recipient’s name, MID number, or date of service has been keyed incorrectly, correct the claim and resubmit on paper or electronically as a new day claim.

Step 3—When All Information Matches Verify that the recipient’s eligibility information has been updated in the state eligibility file by utilizing the NCECS/Recipient Eligibility Verification Web Tool or by calling the AVR system. If the CECS/Recipient Eligibility Verification Web Tool or the AVR system indicates that the recipient is ineligible, submit a Medicaid Resolution Inquiry form to DMA Claims Analysis. Include the recipient eligibility information, the claim, and the RA.

The Claims Analysis unit will review and update the information in EIS and resubmit the claim.


VI. Appendix I – Diagnosis Codes


VII. Appendix II – Additional Resources

General Resource

• Nutrition Entrepreneurs http://www.nedpg.org/

Nutrition Coverage

• www.eatright.org/coverage

Fee Schedule • http://www.eatright.org/feeschedule • Compensation & Benefits Survey of the Dietetics Profession 2009

http://www.eatright.org/Shop/Product.aspx?id=11286 • Tips for contract negotiations and establishing MNT rates.

Myers EF, Michael P, Duester KC. HealthCare Financing Team J Am Diet Assoc 2001 Jun;101(6):624-6 http://www.adajournal.org/article/PIIS0002822301001560/fulltext

• http://www.eatright.org/Members/leadership.aspx?&C=80003209

HIPAA • http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/index.html

http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/index.html�

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